Consent to Charge Credit Debit HSA FSA Card Form

    When I am not present to pay in person at the time of service by Breakthru Counseling &
    Consulting, P. C. (BCC), please charge fees associated with the following BCC client:

    This includes charges for missed sessions not canceled within One (1) Business day of the
    appointment date.

    Visa, MasterCard, AMEX, Discover are accepted by BCC as are Debit cards and most Health
    Savings Account ( HSA) and Flexible Spending Account (FSA) cards.
    The type of card I choose from those listed above to pay for psychological services rendered by
    BCC is:

    My Debit Card
    My HSA
    My FSA

    By my signature below, I authorize Breakthru Counseling & Consulting, P.C. (BCC) to charge
    the card I chose above for psychological services rendered to the above-named BCC client. I
    voluntarily choose and ask that my typed name on the signature line of this document legally
    represent my electronic signature.